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OBJECTIVE—To explore the current use of secondary preventive treatment in survivors of out of hospital cardiac arrest without myocardial infarction (primary ventricular tachycardia/ventricular fibrillation (VT/VF)) in West Yorkshire, and assess the implications of recent studies on the benefits of implantable cardioverter-defibrillators (AICD) in this context. DESIGN—Retrospective analysis of an ambulance service based database of outcome after resuscitation of out of hospital cardiac arrest and the Leeds AICD implantation database. MAIN OUTCOME MEASURES—Mortality, rate of referral for specialist investigation, antiarrhythmic treatment. RESULTS—Twelve month mortality following successful discharge after primary VF arrest was 15%. Of 53 patients with primary VF/VT, 29 apparently did not see a cardiologist during the initial admission. Amiodarone was the most widely used antiarrhythmic agent. Six patients (15%) received an AICD. During the same period 22 patients from the same catchment area received an AICD following an in-hospital cardiac arrest. CONCLUSIONS—Mortality among survivors of non-infarct related prehospital cardiac arrest remains significant, with few patients being referred for specialist investigation. The implementation of recent guidelines on AICD use in cardiac arrest survivors would have resulted in an approximate 60% increase in the total numbers of defibrillators implanted in the West Yorkshire area. Keywords: ventricular fibrillation; ventricular tachycardia; primary arrhythmias; implantable cardioverter-defibrillator

The vascular endothelium consists of a monolayer of cells forming a continuous lining of all blood vessels (with the exception of the spleen). As such, it is in intimate contact with every tissue and is thus in a prime position to exert influence over organ function. The heart contains two types of endothelial cells; vascular and endocardial. Although similar, they show both anatomical and functional differences [1]. The myocardium is richly vascularized, and it has been estimated that any cardiac myocyte is only a few microns away from a capillary vascular endothelial cell. Endocardial endothelial cells (EEC), by contrast, line the cardiac cavities and are in close contact with a relatively small mass of myocardium.

Introduction Accurate and rapid risk assessment is central to the management of patients presenting with acute coronary syndromes (ACS). Simple data from the resting 12-lead electrocardiogram (ECG) is immediately available at first medical contact and may help predict mortality. Methods We regressed 30-day and 2-year mortality on simple ECG variables and clinical characteristics available during admission in 1843 patients with ACS in the EMMACE 2 cohort to generate a parsimonious model that was validated in 550 ACS patients from the EMMACE 1 cohort. The absolute difference between the frontal QRS and frontal T wave axis was calculated as (T wave axis – QRS axis) and if greater than 180 degrees was subtracted from 360, to give a continuous variable between 0 and 180 degrees. Association between mortality and potential predictor factors were quantified by ORs with 95% CIs. An age-QRST angle score was developed and its discriminative performance assessed using the C-statistic. Cox proportional hazards was used to generate survival models, and experiences analysed using Kaplan–Meier estimates. Results The mean (SD) age was 70.1 (13.1) years; and 1547 (61.9%) were male. Of the cohort 942 (37.7%) were non ST-elevation myocardial infarction (NSTEMI), 755 (30.2%) were STEMI and 802 (32.1%) were troponin negative ACS. After adjustment for age, heart failure, previous AMI, heart rate, systolic BP, ST depression, creatinine, elevated cardiac markers and inpatient PCI, the QRS-T angle carried the greatest significance of the ECG parameters. Age-QRST angle score powerfully discriminated 30-day and 2-year mortality (C statistic 0.74, 95% CI 0.71 to 0.78) and 2-year (C statistic 0.76, 95% CI 0.74 to 0.78) mortality, and maintained its performance in the EMMACE-1 validation cohort (C statistic 0.79, 95% CI 0.75 to 0.83) at 30-days and (C statistic 0.76, 95% CI 0.71 to 0.8) at 2-years. Significant differences in survival experience for 2 year survival were evident by age-QRST angle score (Score 0=3.7%, Score 1=14.4%, Score 2=30.2%, Score 3=38.2%, Score 4=57.3%) (Abstract 46 Figure 1). Conclusions Our results indicate that a wide frontal plane QRS-T angle is strongly predictive of mortality and long-term survival following ACS. The proposed model has several advantages over other risk scores in that it is parsimonious, objective (requiring no ECG interpretation) and rapidly available and thus truly near-point.

A morbidly obese woman presented with exertional dyspnoea and leg swelling. Past medical history included deep venous thrombosis and atrial fibrillation. Arterial blood gases demonstrated chronic respiratory acidosis and type 2 respiratory failure. Further evaluation consisted of spirometry (restrictive defect), Epworth scoring, overnight pulse oximetry (median oxygen saturation 68%) and echocardiography (pulmonary artery pressure 59 mm Hg). CT pulmonary angiography excluded signs of acute or …